Abstract
The topic of communication is recognized as a core element of palliative care.1–4 The articles in this issue report on communication strategies ranging from various forms of information, use of video, decision aids, coaching, and communication across settings from outpatient centers, pediatric units, to emergency departments. Communication strategies in these articles address essential issues such as goals of care and patient values and sensitive conversations about medical aid in dying.
Although attention to communication is a hallmark of palliative care and all of the efforts to-date to improve communication are invaluable, most have been pragmatic approaches. By this, we refer to protocols to support breaking bad news, steps to initiate conversations, forms to be completed, and scripts (e.g., “We wish…”) to give us language for these sensitive conversations.
We suggest that true advances in communication in serious illness will only occur through a deeper reflection. Beyond the right words or steps, what are the real human dynamics between clinician and patient? What is the essence of a compassionate conversation?
In 1988, a geriatric fellow, Dr. Greg Sachs, wrote a profound editorial published in JAMA titled “On Deeper Reflection.” 5 His essay described his experience of being called to examine Mrs. Smith, an elderly patient, transferred to the hospital's geriatric unit with multiple pressure sores. Sachs wrote:
“As I moved forward to look deeper into the sore, I thought I saw movement within the wound. I immediately felt repulsed and feared that there might be maggots in this poor woman's hip. I saw no organisms, the wound looked clean, and there was a strange clearness in the center of the crater. I took a deep breath and looked again at the ulcer. Once more I noted movement within the sore. This time the movement paralleled my own motions. I moved closer and peered deeper into the cavity. Right in the center, in the deepest portion of the wound, I saw my own reflection staring back at me.
Again I looked to convince myself that I was indeed seeing my own reflection, moving in the wound as I moved outside of it. I moved the opening in the skin back and forth to see more of the tissues below. As more was revealed, it dawned on me that I was seeing myself in Mrs. Smith's hip prosthesis, the shiny artificial head of her femur mirroring the image of my face. With her immobility, malnutrition, anemia, and infection, this sore would never heal. I took one more look at myself and then left the room.”
Dr. Sachs concluded his powerful essay by reflecting on the health system that had failed the patient and “forgot about her as a human being.”
We challenge readers to think about each article in this issue of JPM related to communication, and to all of our efforts in this area, and to begin to go deeper. Communication is about relationships. For example, Ke and colleagues report in their article in this issue that an Advance Care Planning (ACP) intervention designed to improve decision making between older people and their surrogates in Taiwan “may have enhanced empathy.” A conversation is not just a conversation; it is a connection between father and son and if you look deeply, you know it is not about this moment, but about a lifetime.
In recent years, health care institutions have striven to make improved communication an overall quality improvement goal. However, what does it really mean to “improve communication”? Communication in health care is often associated with tangible skills such as the use of nonverbal cues and plain language. Although those are important factors related to effective communication with patients and families, and are often associated with improved patient satisfaction, research has shown that sometimes, that is not enough. These skills are helpful, but are not guaranteed to create and sustain meaningful relationships between patients and providers. It is important to recognize the relational aspect of communication in health care and the skills required to build these relationships. Beyond our scripts, language, and protocols, what do palliative care clinicians really do in these moments we call communication?
Communication, simply put, is the two-way process of exchanging information, a transactional interchange between people. Communication is inherently a relationship-based process. Palliative care communication has the capacity to create authentic human connection. We communicate to provide information to be understood. At a deeper level, we communicate to understand. Focusing on skills such as showing empathy, providing emotional support, and building trust and rapport will help clinicians to break beyond the surface relationships that often exist in health care and begin to grow more authentic connections. In those clinical moments as described by Dr. Sachs earlier in seeing his own reflection in the pressure sore, it is the clinician who is changed.
In the decades ahead, communication will undoubtedly remain a cornerstone of our field of palliative care. But perhaps it is time for palliative care researchers, educators, and clinicians to go deeper. What does it really mean to share bad news? Or to hear it? What is it really like to comfort a parent who holds a dying child? What does it mean to invite a patient to share their life regrets or need for forgiveness?
Perhaps we have only begun to know what it means to care in serious illness. Perhaps we need deeper reflection.